Who’s truly responsible for the $2.7 trillion medical bill?

As someone who professionally closely tracks the debate over the transformation of the American health care clinical delivery system, I did not learn much new from the New York Times article: The $2.7 Trillion Medical Bill.  I did find the article’s approach useful in explaining how the wide variations in price for procedures contribute to the unnecessary high cost of American health care.

Although the article did document many procedures are more expensive in the United States than in the rest of the world, it concentrated on how colonoscopies average $1,185 in America and $655 in Switzerland.  They could have just as easily focused on MRIs where the American average cost is $1,121 vs. the Dutch average cost of $319 or hip replacement surgery where it costs on average $40,363 in the United States vs. $7,731 in Spain.

I did make several PowerPoint slides from the article for future presentations, but then I did not think much about the impact of the article until days later when I read the letters to the editor.   The article and the response to it provide fascinating and powerful insights into the whole health care debate.

In typical guild based medicine fashion, there are letters from the leaders of the American Society of Anesthesiologists, the American College of Radiology, and the American College of Gastroenterology.  John M. Zerwas, the President of the American Society of Anesthesiologists, offers no evidence-based medical reason for his carefully worded concluding sentence:  “Whether a procedure takes place in an office, a surgical center or a hospital, we believe that sedation is best delivered with physician anesthesiologists involved.”

Dr. Zerwas does not answer the challenge of experts who in the article question the need for physician anesthesiologists to monitor office-based sedatives that are safely administered by a wide range of doctors and nurses in other countries.  Dr. Zerwas does not explain why less expensive nurse anesthetists could not be used.  Dr. Zerwas does not explain why the charges for the sedation are so much more expensive than the charges for the physician performing the colonoscopy.  Dr. Zerwas does not explain that one reason for his society’s rigid stand is that it makes money for his members.

Judy Yee, the chairwoman of the colorectal cancer committee of the American College of Radiology, is quick to point out in her letter to the editor that “Medicare coverage of virtual colonoscopy would make this less expensive test more widely available, attract many more people to be screened and ultimately save lives.”

She does not, of course, point out that this method has the downsides of missing some small lesions and exposing the patient to radiation.  She also does not comment on the financial gains that would be made by her society’s members if virtual colonoscopy replaced standard colonoscopy.

Ronald J. Vender, president of the American College of Gastroenterology, “is disappointed that [the article] unfairly casts outsized blame for high medical costs on colonoscopy and by extension on gastroenterologists.”

In the last sentence of his letter he does provide a nod to shared decision making which could lower costs and improve care: “It is correct that there are screening strategies other than colonoscopy and likewise there are varied patient preferences, so while colonoscopy is our preferred screening strategy, we agree that the best test is one that actually gets taken.”  Dr. Vender does not explain that some of the other screening strategies are less expensive and that his members make a lot of money doing colonoscopies.

Sara Hartley in her letter advocates for “Medicare for all, a national health insurance that eliminates needless profiteering and stealth subsidies” and addresses “another major reason for price inflation:  cost shifting from the uninsured and inadequately covered.”  I think she means cost shifting from the insured to the uninsured, but cost shifting certainly does occur and it makes the whole issue hard to understand and control.

Dr. Kenneth Prager, a New Jersey surgeon, does write about financial incentives in his letter to the editor in response to the original article:

I suspect that if physicians were salaried there would be a substantial decrease in the number of medical procedures performed, including colonoscopies. Money has an insidious way of biasing medical judgment.  When physicians profit from every procedure, it is too easy for some to justify it as in the patient’s best interest even when sound clinical judgment argues the contrary.

I imagine if Dr. Prager bumped into Dr. Scott Ingber, chief medical officer at Mount Sinai North Shore Medical Group, at a conference or cocktail party a lively debate might ensue.  Dr. Ingber, with presumably a straight face, states in his letter that “portraying doctors as overly concerned with financial advancement plants seeds of skepticism in patients when a successful physician-patient relationship rests upon unwavering trust.”

One can just hear Dr. Prager quoting Reagan “to trust, but verify.”

It does not take too much imagination to conjure up that Dr. Prager will refer Dr. Ingber to the ProPublica website that exposes pharmaceutical payments to physicians or to articles about medical device companies paying orthopedic surgeons to use their implants even if the patient is unaware of the cozy financial relationship.

If Claire Burson of New Milford Conneticiut happened to overhear the discussion, she might interrupt to point out the quote from the patient in the article who says, “If a doctor says you need it, you don’t ask.”

Ms. Burson contends that:

Attitudes like that need to change.  Of course you ask. You ask why.  You ask if there are other options.  You ask how the results will affect your treatment.  And you should be able to ask what it will cost.

You knew someone from an insurance company would write in to defend that industry, and Sam Ho, chief medical officer of UnitedHealthcare does not disappoint us.  He writes:

Several health care organizations, including UnitedHealthcare, have introduced online and mobile tools that put relevant medical price information at people’s fingertips, enabling them to comparison shop for health care as they would with other consumer products and services.

Dr. Ho does not explain that health care is not like other consumer products.  I want to buy an iPhone; I don’t want to see a doctor or go to the hospital.  And it is hardly true that we have the tools to comparison shop for medical care.  Didn’t Dr. Ho read about the summer project by Jaime Rosenthal? The Washington University student  documented that only 10 percent of hospitals could quote a complete price for hip replacement and the ones that did ranged in price from $11,000 to $125,000?

Perhaps the last word should go to Lane Rosenthal of Minneapolis:

As your thoughtful case study reported, we are all collectively at fault – from providers, hospitals, pharmaceutical companies, device makers and insurers, to every one of us who demands state-of-the-art technology for everything from a hangnail to a headache, wants antibiotics for a cold, or threatens litigation.  I don’t have the answer for how to untangle the hydra-headed health care mess, but I do know it won’t be solved until across the board we all stop finger-pointing and accept responsibility.

Alas, I guess we all have to change and accept accountability.  And humans are good at neither change nor accountability.

Kent Bottles provides health care leadership consulting and blogs at Kent Bottles Private Views.

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  • Anthony D

    “Who’s truly responsible for the $2.7 trillion medical bill?”

    Well you can’t blame the doctor all the time for driving up cost!!!

    Pretty straight-forward.. I wonder even now how they take it….

    “You know, doctors are people, and we’re being hammered on all sides here.

    It’s the paperwork; it’s insurance; it’s transitioning to electronic
    medical records, so the government can get their mitts into your
    practice. It’s lawsuits; it’s rising overhead and decreasing
    compensation; it’s stress upon stress upon stress.

    And a lot of doctors are going to say, ‘Forget it. I don’t want to do
    this anymore.’ Guys that are 5 or 10 years older than me are just going
    to give up and walk away.”

    And the American Medical Association threw us all under the bus, even
    though only 18% of doctors belong to it. These people are ivory-tower
    academics, and they’re liberals. Most of them are in academic medicine;
    they get a salary with some sort of incentive bonus. They show up to
    work and go home. They’re not in the trenches like me, figuring out how
    to compete with other doctors and pay for malpractice insurance and how
    to hire four people I need to implement the electronic medical records
    and two people I need to deal with insurance.”

    • http://euonymous.wordpress.com euonymous

      There is some truth in what you say, but I take issue with there only being 18% of doctors in the AMA. According to the Bureau of Labor statistics there were (2008) 348,000 employed as docs in the US. With AMA reporting 120,000 practicing medical members that would be over 34%. Even so, the number is smaller than I expected. Yes, the stress on physicians is increasing. I don’t want to rain on your parade or anything, but the rate of change in the world today is increasing stress on everyone. So you are part of a very visible stressed vocation, but not alone in that issue and likely not the most stressed profession. And, by the way, you may need more than 4 people to implement EMR because there are no intelligent standards and whatever you implement will probably need to be replaced in a couple years or so as you learn why it isn’t as useful as the salesperson said it was. Stress? Yeah, baby. Another reason why doctors are opting to combine practices rather than carry the weight of the system themselves. Please don’t blame “liberals” for all the grief; it was Mitt Romney who set the standard in MA for the current healthcare environment, what conservatives would prefer to call “Obamacare.”

      • Guest

        Obama is our President and has been for five years now. He set the Federal healthcare policy known as the “Affordable” (lol) Care Act, including the EMR requirements, not former Massachusetts State Governor and failed Presidential Candidate Romney.

        You’re welcome.

        • meyati

          And my grandson, 26, a part-time pizza delivery man, is trying to figure out how to pay the fines for not having Obama insurance, because he can’t afford Obamacare. We live in a state that just hasn’t recovered economically, partly because we were at the bottom of the barrel before the meltdown.

    • Guest

      “In the early 1950s, about 75% of US physicians were AMA
      members. That percentage has steadily decreased over the years. In June, at the annual meeting of its policy-making body, the House of Delegates, the AMA announced that it lost another 12 000 members last year.

      “That brings total membership below 216 000. Up to a
      third of those members don’t pay the full $420 annual dues, including medical students and residents. Not counting those members, somewhere in the neighbourhood of 15% of practising US doctors now belong to the AMA.”

      source:

      http: //www. ncbi. nlm. nih. gov/pmc/articles/PMC3153537/
      9 August 2011

  • Sophie Balzora, MD

    The professional GI societies’ stance is an insightful and important one – engendering distrust in endoscopists performing a procedure like colonoscopies that are well-supported and evidence-based in showing a >50% decrease in colorectal cancer mortality is a dangerous and misleading message. Highlighting colonoscopies in the subtitle of the NYT article as the primary cause of our many healthcare problems as a country is misleading and confusing to the patients we treat. Prevention is an underappreciated aspect of American medicine. Dr. Prager, a pulmonologist and medical ethicist (not a surgeon as you stated in your article), certainly has a valid point in stating that medicine and reimbursement on quantity, and not quality, is a big problem. That being said, hopefully our healthcare system will change for the better when quality indicators are used as a standard for which physicians can strive to practice towards, and patients can appreciate.

    • Guest

      Another gastroenterologist who does colonoscopies, drumming up business for more colonoscopies? Sorry, but this is why people get cynical.

      • Sophie Balzora, MD

        It’s ignorant to assume that all gastroenterologists make a profit off of procedures; there are salaried physicians, and physicians who work solely at academic centers who derive absolutely no monetary compensation for whatever method of screening that is chosen. After a discussion with the patient on what screening modality works best for his/her clinical status and personal preference, an appropriate method is chosen with the patient’s best interest, and what will benefit his/her health and well-being as the driving force.

        • buzzkillerjsmith

          Ignorant is a strong word, Dr. B. Perhaps medical school and residency have led you to underestimate the cognitive capacities of others. You might want to rein that in a bit, young doc.

    • buzzkillerjsmith

      You think others think that colonoscopies the cause of our HC spending crisis?! The readers of the NYT aren’t that confused, Dr. B. We’re not talking about viewers of Fox News here. And I suspect colonoscopies are only one intervention that they will highlight in their series.

      The problem is a sum of a large number of sometimes overpriced interventions, each of which contributes only a little by itself. People understand this.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    And let’s not forget that since the government has become a full partner in “shared decision making”, colonoscopies are now “free”, including any necessary polyp removal, which sort of settles the question, I would think.

    • Guest

      “If you think health care is expensive now, wait until you see what it costs when it’s free.”
      -PJ O’Rourke

  • azmd

    At the end of the day, we appear to expect doctors in full-time clinical practice to do the following:

    Pay, out of their own pockets, upwards of $200,000 for medical training after having already paid for four years of undergraduate education.

    Spend the subsequent 3-7 years working 80 hour weeks for a wage which in most cases is not even the equivalent of minimum wage.

    Undergo sleep deprivation for a significant portion of their training and then in some cases for the rest of their careers in order to ensure round-the-clock care for patients.

    Commit to a high-stress occupation in which mistakes can and will cost people their lives and in which there is an inherent professional expectation that the physician’s personal life will, at all times, take second place to the needs of the patient.

    Commit to a workweek of up to 80-100 hours.

    Submit to very substantial regulation, which increases daily and in many cases does not add anything other than layers of bureaucratic tasks to the workday.

    Meekly agree with media and public assessments of them as gravely deficient in their work, attitudes, expectations for pay, etc., and agree to work harder.

    Let’s not kid ourselves. Doctors are not saints, and it would be foolish of us to expect them to be. There are not enough saints in the world to provide the healthcare that we need. People go into medicine for a variety of reasons, one of which is the entirely acceptable expectation that they will be able to make a comfortable living, one which will offer them an appropriate level of compensation for highly stressful work.

    Attempts to restructure our healthcare delivery system to minimize physician compensation past a certain point will result in our smartest, most motivated students seeking other careers. A physician has the right to expect, not to become rich, but to be able to support his or her family in a way that allows their children to be educated. The average salary of a primary care provider in this country is now at a level where their children qualify for financial aid at some colleges. You simply can’t expect people to continue to go into an occupation with those working conditions, and guess what, they aren’t. Do we really want to see that happening in medicine across all specialties?

    • buzzkillerjsmith

      You keep talkin’ like this and you’re gonna kill my buzz.

  • buzzkillerjsmith

    It’s multifactorial:

    1. Doctors here, especially proceduralists, get paid more than they do in other countries. The guild behavior that Dr. B. describes is part of this. Gouging (usual fees for an area) is rampant.

    2. Hospitals gouge. Facility fees. Need I say more?

    3. Hospitals gouge. Opaque pricing. Need I say more?

    4. Doctors and hospitals drum up business by advertizing low-yield but high cost stuff. The local urologist here had a free prostate cancer screening “discussion” for the local oldsters. Revolting.

    5. Insurance companies gouge. It is their business model.

    6. Drug and device companies gouge. It is their business model.

    7. Patients sometimes prefer high-tech options when less expensive ones would suffice. They have been socialized to think this way. Ever watch TV commercials for pharma in the evening? “Talk to your doctor.”

    7. The government is unwilling to identify and take on the predators in the medical system. It has no incentive to do so since the predators regurgitate some of their partially-digested carrion to your local Congresspersons.

    Truth be told, get all of this under some control would require significant government intervention, much more than Obamacare is trying. I doubt this country in its current political state would put up with that. So get out the checkbook.

    • Guest

      “The government is unwilling to identify and take on the predators in the medical system. It has no incentive to do so since the predators regurgitate some of their partially-digested carrion to your local Congresspersons.”

      Beautifully put.

    • Fred Ickenham

      Docs in these comparison countries also don’t have the predatory tort system, and other sourses of overhead cost, so typically, for nonproceduralistsa at least, they have more not less disposable income.

  • Lynne Hagan

    Would anyone like to estimate or cite how much of the increase in healthcare spending is accounted for government legislation?